Integrating health and social care: a test for even the strongest leaders

While pilot results give grounds for optimism, implementing change on a national scale will provide a tougher challenge

A patient on the elderly care assessment unit at Birmingham Heartlands hospital. The integration of health and social care is the subject of extensive pilot studies. Photograph: Christopher Thomond for the Guardian
Christopher Thomond/Guardian

A key issue in the continuing debate about care services in England is the need for more integrated care. It is accepted across the political spectrum that for too long, NHS and social care providers have failed to co-ordinate their work fully. As a consequence, the effectiveness of care has been reduced and the patient experience diminished, while scarce resources have not been best used.

Poor care integration is particularly important given the continuing increase, as the population ages, in the numbers of people living with long-term conditions such as diabetes and heart disease. Care for these people will inevitably require complex co-ordination of services if it is to be effective.

The Department of Health recently released an independent evaluation of integrated care pilots carried out by Ernst & Young and Rand Europe. The evaluation looked at the work of 16 pilots established in 2009. Each was designed to support closer working between different care providers – most focused on integrating general practice, community nursing and social services – but some attempted to integrate hospital services with those provided in the community.

The evaluation found that, from the perspective of pilot staff, integration was a success. A majority felt that they had enjoyed better teamworking and communication, had increased the breadth and depth of their jobs and that, overall, patient care had improved as a result.

Analysis of hospital care showed that the pilots had failed to reduce the numbers of emergency admissions to hospital, one of their key aims, but they had reduced significantly outpatient hospital attendances and admissions for planned care. This meant that the overall use of hospital care had decreased as a result of integration.

Patient responses to the pilots were less positive. While they reported receiving more care plans and that care was better co-ordinated when they were discharged from hospital, they also found it more difficult to see the nurse of their choice, felt listened to less frequently and felt less involved in decisions about their care.

Overall, these results provide grounds for cautious optimism that integrated care may deliver at least some of its hoped for benefits.

However, it is a big assumption to make that even modest gains achieved in a pilot environment will be easily translated to the NHS and social care systems generally.

The evaluation found that when implementing change on a relatively small scale, the complexity of integration across organisational boundaries challenged even the generally strong pilot leaders.

These leaders faced a number of obstacles, including having to cope with different procedures and regulations within the different organisations that were integrating. This made some objectives, such as pooling budgets across sectors, difficult.

Pilots also frequently found what they felt to be bureaucratic barriers getting in the way and slowing down progress. In one case, the national co-operation and competition panel felt it had to rule on whether the proposal to integrate services contravened competition rules within the NHS.

In many pilots, having leaders drawn from clinical staff was a big advantage in terms of motivating others to participate and in giving credibility to the venture. However, by being outside of the formal management chain of the NHS, those clinical leaders often had to seek approval further up the chain – something that may change as new clinical commissioning groups take charge of NHS commissioning from next year.

It is significant that the pilots were selected from among willing volunteers. Moreover, they received financial and other support from Whitehall and had the prestige of being national pilot sites.

Those following after will have to succeed in a different, and in some ways harsher, environment. This will place an even greater premium on leadership capability.